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Vulvodynia

Definition

The vulva consists of the external genital organs of the female including the labia majora, labia minora, clitoris, and vestibule. 

Vulvodynia refers to pain involving any of these areas.

Background

International Society for the Study of Vulvovaginal Disease defines vulvodynia as chronic vulvar discomfort characterized by complaints of rawness, burning, irritation, or stinging. 

Vulvar pain related to a specific disorder

  • Infectious (related to herpes, yeast, or other infections)
  • Inflammatory (inflammatory skin disorders)
  • Neoplastic (benign or cancerous changes)
  • Neurologic (involving damage to sensory nerves of the vulva-herpes or nerve compression)

Vulvodynia 

  • Generalized (all over or non-specific area)
    • Provoked (sexual,non-sexuall, both)
    • Unprovoked (occurring spontaneously without touch or pressure)
    • Mixed (both)
  • Localized (specific area: vestibulodynia, clitorodynia, hemivulvodynia)
    • provoked
    • unprovoked
    • mixed

Generalized vulvodynia has also been called hyperesthesia of the vulva, dysesthetic vulvodynia, vulvar dysesthesia, and essential vulvodynia. Provoked vestibulodynia has also been called vulvar vestibulitis syndrome, vestibular adenitis, minor vestibular gland syndrome, and localized provoked vestibulodynia. This is important because women who have seen multiple providers may have heard their symptoms described as many different problems. This can be confusing and, occasionally, frightening. All of these terms are descriptions of the same conditions.

It is often difficult for women to discuss vulvar pain with their providers. It is a serious problem that should be addressed. Like other pain syndromes, vulvar pain has been linked to high healthcare costs, lower productivity at work, and problems in interpersonal relationships. This is often compounded by the negative impact on women’s sexual relationships.

Presentation

Vulvar pain is a fairly common problem. It has been reported in up to 16% of women and can occur at any age.  It is typically described is burning, stabbing, rawness, or irritation. Some women experience this when trying to place a tampon or have intercourse or even wearing tight clothing. Others complain of similar symptoms without any aggravating factors.

Some symptoms may be attributed to other conditions but are actually a manifestation of vulvodynia or coexisting conditions. Complaints of frequent bladder or vaginal infections, urinary urgency or frequency, inability to achieve vaginal penetration, and pain with sitting are common.

Most women have experienced pain for years rather than months. Over one third have never discussed the symptoms with a provider, and almost two-thirds of those who have, have seen at least three providers. In one study, over half the women who sought care had seen between 4 and 9 providers.

Causes/etiology/differential diagnosis

Chronic vulvar pain due to specific causes and vulvodynia often cause similar symptoms. Vulvodynia is a term reserved for pain in which no other physical cause has been found. The diagnosis of vulvodynia is one of exclusion. A few more specific causes of chronic vulvar pain that should be excluded are listed.

Causes of vulvar pain

Infectious

Chronic yeast - bacterial vaginosis

Sexually transmitted infections - Genital herpes, HPV, syphilis, chancroid, LGV, trichomoniasis

Inflammatory

Allergic or contact dermatitis - Soups, detergents, excessive hygiene causing

Hormonal - Atrophic vulvovaginitis

Skin conditions - Lichen sclerosis, lichen planus, lichen simplex chronicus, aphthous ulcers, Bechet’s disease, pemphigoid

Neoplastic

Malignant Cancer - Squamous cell carcinoma, basal cell carcinoma, malignant melanoma, adenocarcinoma

Other - Paget’s disease, VIN

Neurologic

Nerve Damage - Specific nerve lesion, pudendal neuralgia, spinal cord injury

Neuropathic Pain Syndrome - Diabetic neuropathy, multiple sclerosis, lumbosacral nerve issue, herpes infection

Associated conditions - Fibromyalgia, TMJ, migraine, Irritable bowel syndrome, interstitial cystitis

The cause of vulvodynia is not known. There are may be some predisposing factors or triggers. Genetics, hormonal factors, recurrent infections, physical, emotional, or sexual abuse, allergies, age at first intercourse, pregnancy history, surgical and medical factors, and adverse life experiences may all play a role. Different contributing factors are present in different women.

How to diagnose

The diagnosis of vulvodynia involves:

  • The exclusion of known causes of vulvar pain.
    • Listening to the history of the condition. Characterization of the pain, duration, aggravating factors, and remedies tried are all important.
  • A thorough social, medical, family, surgical, and psychologic history are necessary, including medications and known allergies.
    • Part of this evaluation includes a discussion of the impact of the pain on patients’ relationships and well-being.

A complete physical exam is part of the evaluation with emphasis on the vulva and other genital areas. This may include vulvoscopic exam which uses some magnification to exam the vulvar tissue. A cotton swab test for sensitivity is also performed. Deep pelvic organs and pelvic floor muscles are also examined unless the external pain is too severe.

Evaluation may include blood tests, microscopic evaluation of vaginal discharge, cultures, or biopsies. The history or exam might suggest conditions that required additional evaluation by CT scan or ultrasound, evaluation of the GI or urologic organs, or referral to additional providers for evaluation and/or treatment.

Treatment options (least to most invasive)

The treatment of chronic vulvar pain depends upon the diagnosis and the individual. When a specific disorder is diagnosed, treatment options are discussed, and a treatment plan is outlined.

Generalized vulvodynia treatment options range from minimally invasive creams to more aggressive therapies. Some of the treatment options have shown benefit in clinical scientific studies while others have shown some benefit only on a case-by-case basis.

Vulvar care strategies

Cotton underwear washed without perfumes or softeners, mild soaps, avoid excessive scrubbing of the labia, dye-free cotton pads with menses, adequate lubrication without propylene glycol, gentle rinsing after urination. Strategies to minimize irritation have positive clinical results without extensive scientific support. Very low-risk therapy.

Diet modification

Low oxalate diet, oral calcium citrate supplementation. Some reported benefit; no support in scientific studies; very low risk.

Topical medications

Anesthetics (excluding benzocaine), plain petrolatum, capsaicin, nitroglycerin, compounded combinations of topical antidepressant or anit-seizure medications. Results in clinical trials vary, some topical medications can be associated with burning.

Antifungals, estrogens -Medications for coexisting problems that don’t treat the generalized vulvodynia itself.

Corticosteroids, Benadryl, benzocaine products - May worsen condition, cause sensitization or allergic reactions

Oral medications

Antidepressant medications help block pain signals in the peripheral nervous system. TCA’s (amitriptyline, nortiptyline, and desipramine) are first line. SNRI’s (venlafaxene, duloxetene) are also being used. Multiple options, varying benefit in clinical trials, medical risks and side effects, necessary to decrease medications slowly when discontinuing.

Antiseizure medications - gabapentin, pregabalin. Monitor levels, increase slowly.

Pain medication - anti-inflammatory medications, opioids. Only when absolutely necessary ;Use of narcotic contract and monitoring is essential; risks of constipation, drowsiness, addiction.

Nerve block

Vulvar, pudendal, spinal nerve blocks. Clinical results vary.

Pelvic floor physical therapy

Various physical therapy techniques and biofeedback. Good results with experienced providers. Especially beneficial if there is evidence of pelvic floor muscle spasm.

Nerve stimulator

Spinal cord stimulator. Not FDA approved for use for vulvodynia. Some positive results.

Psychotherapy

Treat associated psychosexual and relationship issues. Multiple studies show the benefit of multidisciplinary treatment.

Provoked Vestibulodynia

PVD, previously referred to as vulvar vestibulitis syndrome, is a localized, provoked pain specific to an area of the vulva between the labia minora at the vaignal opening. It is a type of vulvadynia.

Pain may have always been present, noted by a woman the first time she tried to use a tampon or attempt intercourse, or it may develop over time. The diagnosis is based on symptoms and findings on physical exam. The cause is unknown. It may be associated with a number of conditions that, together or separately, in some women, lead to symptoms of pain to touch at the vaginal opening. Genetic predisposition, inflammatory or immune responses, hormonal changes, trauma, and nerve injury may be contributors.
Most treatments listed have been evaluated in small scientific studies but not in large comparison trials. Some have not been studied. Not all treatments have the same benefit in all patients.

  • Topical medications
  • Diet modification
  • Oral medications
  • Pelvic floor physical therapy
  • Local injections
  • Nerve blocks
  • Psychotherapy
  • Surgery 

Resources

International Society for the Study of Women’s Sexual Health

National Vulvodynia Association

Vulvar Pain Foundation

References

Goldstein AT, Pukall CF, Goldstein I. Female Sexual Pain Disorders: Evaluation and management. Blackwell Publishing Ltd., 2009.

Haefner HK, Collins ME, Davis GD, Edwards L, Foster DC, Hartman ED, et al. The vulvodynia guideline. J Low Genit Tract Dis 2005;9:40–51. Available at: http://www.jlgtd.com/pt/re/jlgtd/pdfhandler.00128360-200501000-00009.pdf. Retrieved March 15, 2006.

International Society for the Study of Vulvovaginal Disease (ISSVD)

Lonky LM, Edwards L, Gunter J, and Haefner HK. Vulvar pain syndromes: causes and treatment of vestibulodynia, OBG Manag. Nov 2011; 23(11):24-33.

National Vulvodynia Association

Pagano, R. Vulvar vestibulitis syndrome: An often unrecognized cause of dyspareunia. Female sexual pain, vulvar pain clinics. Behavioral medicine Institute of Australia, copyright 2001-2011. Accessed 14 March 2012.

Ventolini, Gary. Measuring treatment outcomes in women with vulvodynia. J Clin Med Res. 2011; 3(2):59-64.

Vulvodynia ACOG committee Opinion No. 345, Oct 2006 reaffirmed 2008. Accessed 15 March 2012.